What Type of Acne Scars Do You Have? Here's How Each Is Treated

Acne scars are not a single condition. The term covers at least three structurally distinct scar types, each caused by a different pattern of tissue loss during the healing process, and each requiring a different clinical approach. Treating them interchangeably is one of the most common reasons people spend money on procedures and see little change.

When a deep or inflamed pimple damages the dermis, the layer beneath the surface, the skin attempts repair by producing collagen. When that repair is uneven or insufficient, a depression forms. The shape of the depression depends on how the collagen collapsed and how deep the original damage went. This is why two people with similar acne histories can end up with completely different scar patterns, and why a single person may have more than one type on the same area of skin.

Ice pick scars are narrow channels that extend deep into the dermis, sometimes reaching the subcutaneous layer. They look like small, sharp punctures and are most common on the cheeks. Because they are deep and have a very small surface opening, resurfacing treatments, lasers, chemical peels, microneedling, cannot reach the base of the scar. The walls of the channel remain intact below the surface, so surface-level treatments produce limited improvement at best.

The most effective approach for ice pick scars is a technique called punch excision, where the scar is surgically removed with a small circular blade and the edges are sutured closed. Another option is punch grafting, where the excised site is filled with a small skin graft. These are in-clinic procedures that require local anaesthesia and carry a short healing period. A dermatologist assessing ice pick scars will also consider TCA cross, the controlled application of trichloroacetic acid directly into the scar channel to stimulate collagen from the inside. This is not a peel applied to the skin's surface; it is a targeted chemical application and must be performed by a trained clinician. Incorrect application can worsen scarring.

Boxcar scars have a broader base and sharply defined vertical edges, giving them a rectangular or oval appearance. They sit at a shallower depth than ice pick scars, which makes them more responsive to resurfacing. Ablative fractional lasers, such as fractional CO2, work by creating controlled columns of thermal injury in the skin, prompting collagen remodelling over several weeks. Multiple sessions are typically required, and results vary depending on scar depth, skin tone, and individual healing response.

Subcision, a procedure where a needle is inserted beneath the scar to release fibrous bands tethering the base, can help lift the floor of a boxcar scar before resurfacing. Dermal fillers are sometimes used as a temporary measure to raise the scar base, though this is not a permanent correction. Anyone with darker skin tones should discuss post-inflammatory hyperpigmentation risk with their dermatologist before any laser or ablative treatment, as the risk is meaningfully higher and the choice of device matters significantly.

Rolling scars have sloping, wave-like edges and a soft appearance that becomes more pronounced when the skin is stretched. The characteristic undulation happens because fibrous tissue beneath the scar pulls the skin surface downward unevenly. Unlike ice pick or boxcar scars, the problem is not primarily the scar's depth but its attachment below the surface.

Subcision is the most directly targeted treatment for rolling scars, because it severs the fibrous bands causing the tethering. After subcision, the scar base is free to rise. This is often combined with microneedling with radiofrequency, or with platelet-rich plasma, to stimulate collagen in the space created. Rolling scars tend to show the most visible improvement from subcision compared with the other types, though several sessions are usually needed and results are gradual over months rather than weeks.

Many clinics offer a standard acne scar package, a set number of laser sessions or microneedling treatments, without first identifying which scar types are present. For ice pick scars, this approach is unlikely to produce meaningful results. For rolling scars, it may miss the subcision step that does most of the work. A proper assessment involves a dermatologist examining the scars in good lighting, often stretching the skin to assess tethering, and sometimes using a dermatoscope. The treatment plan that follows should name the scar types present and explain why each chosen technique addresses the specific structural problem.

Scar treatment also takes time. Collagen remodelling continues for three to six months after a procedure, which means the final result of any session is not visible immediately. Starting a second treatment before the first has finished its biological effect makes it difficult to assess what is actually working. Patience is not a marketing line here, it is how the tissue biology operates.

The distinction between scar types is not a technicality. It is the difference between a treatment plan that addresses what is structurally happening under your skin and one that does not.

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